Outcome of Purely Endoscopic Surgery for Pituitary Adenoma Orphee Makiese MD, Promod Pillai MD Venko...
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Transcript of Outcome of Purely Endoscopic Surgery for Pituitary Adenoma Orphee Makiese MD, Promod Pillai MD Venko...
Outcome of Purely Endoscopic Outcome of Purely Endoscopic Surgery for Pituitary AdenomaSurgery for Pituitary Adenoma
Orphee Makiese MD, Promod Pillai MD Orphee Makiese MD, Promod Pillai MD Venko Filipce MD, Mario Ammirati MD,MBAVenko Filipce MD, Mario Ammirati MD,MBA
Dept. of Neurological SurgeryDept. of Neurological SurgeryOhio State University Medical CenterOhio State University Medical Center
Columbus , OHColumbus , OH
NASBS-2008
A Systematic Literature A Systematic Literature ReviewReview
A Systematic Literature ReviewA Systematic Literature Review
I. INTRODUCTIONI. INTRODUCTION
Applying new technology: a challenging change to Applying new technology: a challenging change to surgical routinessurgical routines
After feasibility study, using technology to treat patients After feasibility study, using technology to treat patients requires strict follow-ups and comparisons with reference requires strict follow-ups and comparisons with reference (s) technique (s)(s) technique (s)
In order to fully and safely benefit patients In order to fully and safely benefit patients
NASBS-2008
Over last decade, endoscopic used to assist Over last decade, endoscopic used to assist trans-sphenoidal approachestrans-sphenoidal approaches
Review of the literature outcome of pure Review of the literature outcome of pure endoscopic assisted pituitary surgery endoscopic assisted pituitary surgery
A Systematic Literature ReviewA Systematic Literature Review
NASBS-2008
I. INTRODUCTION (Cont’d)I. INTRODUCTION (Cont’d)
A Systematic Literature ReviewA Systematic Literature Review
II. MATERIALS & METHODSII. MATERIALS & METHODS
Medline Pubmed (PM) data base (Medline Pubmed (PM) data base (English)English)
Publications ranging from early 1990’sPublications ranging from early 1990’s to 2007 to 2007
Eligible studies all included outcome Eligible studies all included outcome measurementsmeasurements
NASBS-2008
A.A. MaterialsMaterials
A Systematic Literature ReviewA Systematic Literature Review
Outcomes measurement ofOutcomes measurement ofMajor and Major and Minor complicationsMinor complications
Remission and recurrence rates evaluationRemission and recurrence rates evaluation Comparison to microscopic survey and Comparison to microscopic survey and
systematic literature reviewsystematic literature review
NASBS-2008
B. Methods ObjectivesB. Methods Objectives
A Systematic Literature ReviewA Systematic Literature Review
C.C. Inclusion CriteriaInclusion Criteria
Purely endoscopic studies for pituitary Purely endoscopic studies for pituitary adenoma (+10 patients)adenoma (+10 patients)
Adult pituitary surgeryAdult pituitary surgery Trans-sphenoidal surgery (sub labial or nostril) Trans-sphenoidal surgery (sub labial or nostril)
NASBS-2008
A Systematic Literature ReviewA Systematic Literature Review
Diagnosis confirmed by MRI and Diagnosis confirmed by MRI and endocrinology screeningendocrinology screening
Histopathology-definite diagnosis of pituitary Histopathology-definite diagnosis of pituitary adenomaadenoma
Studies including outcome measurementsStudies including outcome measurements Follow-up more than 6 monthsFollow-up more than 6 months First surgeryFirst surgery
NASBS-2008
C. C. Inclusion Criteria (Cont’d)Inclusion Criteria (Cont’d)
A Systematic Literature ReviewA Systematic Literature Review
D.D. Exclusion CriteriaExclusion Criteria
Following cases were disregarded…Following cases were disregarded…Recurrent pituitary tumorsRecurrent pituitary tumorsSubjects to previous endoscopic approachSubjects to previous endoscopic approachSubmitted to prior radiationSubmitted to prior radiation
NASBS-2008
A Systematic Literature ReviewA Systematic Literature Review
III.III. RESULTSRESULTS
16 Articles: 16 Articles: 2 Class II2 Class II 2 Class III2 Class III 12 Class IV 12 Class IV
From 105 articles “From 105 articles “Pituitary and Endoscope Pituitary and Endoscope Surgery’’, PM termsSurgery’’, PM terms
Selection from a pool of 26617 articles on Selection from a pool of 26617 articles on “Pituitary surgery” PM terms“Pituitary surgery” PM terms
NASBS-2008
A Systematic Literature ReviewA Systematic Literature Review
37.5% NA, 25% EU, 25% Asia, 12.5% ME37.5% NA, 25% EU, 25% Asia, 12.5% ME 974 patients: 974 patients:
444 non functioning444 non functioning480 functioning480 functioning709 macro adenoma709 macro adenoma265 micro adenoma265 micro adenoma
Mean age=46 yrs; 51% female Mean age=46 yrs; 51% female NASBS-2008
III.III. RESULTS (Cont’d)RESULTS (Cont’d)
Identical methodology for microscopic groupIdentical methodology for microscopic group Statistical comparison of groups based on Statistical comparison of groups based on
homogeneity and known epidemiologic homogeneity and known epidemiologic pathologypathology
Assuming different surgeons and distinct Assuming different surgeons and distinct populationpopulation
16 articles for endoscopic group 974 16 articles for endoscopic group 974 16 articles for microscopic group 197116 articles for microscopic group 1971
NASBS-2008
A Systematic Literature ReviewA Systematic Literature Review
III.III. RESULTS (Cont’d)RESULTS (Cont’d)
Authors Year Type of Study Study Population
Mean Age(Y) F H Duration of Study
Macro Micro
Jho H D and Carrau R L
1997 Clinical, R 44 38(14-88) 19 25 1993-1996 31 13
Sheehan MT et al 1998 Clinical, RC 26 59.2(25-80) 8 18 1995-1997 26 0
ILan K et al 1999 Clinical, RC 18 1996-1997 12 6
Badie B et al 1999 Clinical, PC 16 48 6 10 1996-1999 9 7
Ogawa T et al 2000 Clinical, RC 13 49.1(19-73) 6 7 1996-1999 11 2
Cappabianca P et al 2002 Clinical, R 146 46.1(16-74) 76 68 1997-2001 125 21
Cho D Y et al 2002 clinical, PC 22 45.3(22-60) 22 0 1996-2000 11 11
White D R et al 2004 Clinical, RC 50 41.1 26 24 2000-2002
Kabil M S et al 2005 Clinical, RC 300 46(16-75) 176 124 1998-2004 235 65
Netea-Maier R T et al 2006 Clinical, R 35 41(14-68) 25 10 1998-2004 6 29
Rudnik A et al 2006 Clinical, R 63 48.3(11-77) 34 29 2001-2002 52 11
Kenan K et al 2006 Clinical, R 78 44.7(11-67) 1997-2005 67 11
Jain A.K. et al 2007 Clinical, P 10 40.1 6 4 9 1
Dehdashiti AR et al 2007 Clinical, R 25 42 19 6 2004 -2007 7 18
Charalampaki P et al 2007 Clinical, R 50 56(28-84) 30 20 2004-2005 41 9
Zhang X et al 2007 Clinical, R 78 45.1(15-76) 42 36 1998-2005 67 11
Authors Year Type of Study Study Population
Mean Age(Y) F H Duration of Study
Macro Micro
Sheehan MT et al 1998 Clinical, RC 44 57.8(32-85) 13 31 1995-1997 44
Laws and Semple 1999 Clinical, R 105 38.5 (6-78) 83 22 1992-1997 13 92
Zhang X et al 1999 Clinical, R 208 47.5(16-71) 110 98 1982-1997 189 0
ILan K et al 1999 Clinical, RC 20 1993-1995 11 8
Badie B et al 1999 Clinical, PC 21 43 11 10 1996-1999 12 6
Ogawa T et al 2000 Clinical, RC 18 49.4(23-73) 8 10 1996-1999 16 2
Kaltsas et al 2001 Clinical, R 67 1993-1998 50 17
Kreutzer et al 2001 Clinical, R 57 43.9(16-71) 37 20 1992-1998 38 19
Rees D A et al 2001 Clinical, R 54 41.3(14-73) 42 12 1980-2000
Shimon I et al 2002 Clinical, R 74 39(8-72) 64 10 1990-2000 3 71
Cho D Y et al 2002 Clinical, PC 22 46.7(18-56) 21 1 1996-2000 10 12
DE P. et al 2003 Clinical, R 47 61(29-86) 24 23 1990-2001 35 12
Höybye C et al 2004 Clinical, R 34 40(13-74) 26 8 1990-1999 2 32
White D R et al 2004 Clinical, RC 50 43.5 17 33 1996-1999
Mortini P et al 2005 Clinical, R 1140 43(8-82) 681 459 1990-2002 788 72
Jain A.K. et al 2007 Clinical, PR 10 31.6 5 5 8 2
A Systematic Literature A Systematic Literature ReviewReview
A.A. Comparability: Sex, Age and Comparability: Sex, Age and Adenoma SizeAdenoma Size
Endoscope Microscope P-value
Mean Age 46 44.6 0.6276
Sex 495F, 381M 1189F, 795M 0.0942
Macro adenoma 77% 78% 0.5168
Micro adenoma 23% 22% 0.51680.5168
Functioning 52% 77% 0.00010.0001
Nonfunctioning 48% 33% 0.00010.0001
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Endoscope Microscope Ciric National Survey 1997
Relative Risk
P-value
CSF 3.6% 2.6% 3.9% 1.45 0.0736
Meningitis 0.71% 0.2% 1.5% 3.48 0.0435
Sinusitis 1.9% 0.3% 8.5% 6.34 0.0027
Vascular injury 1.3% 0.57% 1.1% 2.38 0.0563
DI-Transient 5.6% 8.1% 0.68 0.0697
DI permanent 3.5% 3.6% 17.8% 0.99 0.9632
Visual loss 1.7% 0.36% 1.4% 4.88 0.0005
Major Complications 14.7% 10.7% 1.26 0.002
B.B. Major Complications and Major Complications and ComparisonsComparisons
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A Systematic Literature A Systematic Literature ReviewReview
C.C. Minor Complications and Minor Complications and Comparisons Comparisons
Endoscope Microscope Ciric National survey 1997
Relative Risk P-value
Epistaxis 0.72% 0.26% 3.4% 2.72 0.1286Septum perf 0.62% 0.67% 6.7% 0.92 0.8583Nerves injury 0% 0.1% 1.3%Anosmia 0.31% 0%Crusting 0.62% 0.21% 3.0 0.1491Synechia 0.52% 0.36% 1.42 0.7689Saddle nose 0% 0.05%Minorcomplications
2.8% 2.3% 1.138 0.49550.4955
NASBS-2008
A Systematic Literature A Systematic Literature ReviewReview
D.D. Length of Stay in HospitalLength of Stay in Hospital
Endoscope Microscope P-value
Length of stay in hospital 3.34 days 6.1 days 0.09840.0984
too few too few values in values in micro gpmicro gp
NASBS-2008
A Systematic Literature A Systematic Literature ReviewReview
E.E. Death, Follow-up and Death, Follow-up and RemissionRemission
Endoscope Microscope Ciric National survey 1997 Relative Risk
P-value
Death 0.6% 0.4% 0.9% 1.44 0.73
Follow up 19.2 months
43.3 months
Remission 65.2% 65.3% 0.998 0.947726
Recurrence 0.1% 4.2% 0.024 1.78*10-10
too few values in endosc gp
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CONCLUSIONSCONCLUSIONS
Two accurate observations that:Two accurate observations that:
Statistics seem SIGNIFICANT for microscope Statistics seem SIGNIFICANT for microscope performed on major complications but…performed on major complications but…
NON SIGNIFICANT on minor complications NON SIGNIFICANT on minor complications
NASBS-2008
A Systematic Literature A Systematic Literature ReviewReview
A. A. Preliminary RemarksPreliminary Remarks
Study accuracy would require more …Study accuracy would require more … Report data about length of stay in hospital for Report data about length of stay in hospital for
microscopic group microscopic group Report data about recurrence and follow-up for Report data about recurrence and follow-up for
endoscopic group endoscopic group Comparative studies to further meta-analysis studyComparative studies to further meta-analysis study
NASBS-2008
A Systematic Literature A Systematic Literature ReviewReview
B.B. Research recommendationsResearch recommendations